Transcript Cost-effectiveness

Interactive Introduction
cost effectiveness
Jan J. v. Busschbach, Ph.D
Viersprong Institute for studies on Personality
Disorders (VISPD)
[email protected]
+31 164 632200
Department of Medical Psychology &
Psychotherapy, Erasmus University Medical Center
New cancer therapy
Symptoms
Drug X
Drug Y
Survival days
Days sick of chemotherapy
Days sick of disease
TWiST
300
10
100
190
400
150
30
220
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Time Without Symptoms of disease and
subjective Toxic effects of treatment
• TWiST
– Developed by Richard Gelber (statistician)
• In search for a typical “cancer” problem
– Often prolonged life but also a reductions in
quality of life
• At the beginning (side effects)
• At the end
– Only count the days without symptoms of
disease and subjective toxic effects of the
treatment
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Fit new therapy in fixed budget
• 50 patients each year (per hospital)
– Drug x: 50 x euro 1.750 = euro 87.500
– Drug y: 50 x euro 2.000 = euro 100.000
• Drug budget for x or y = euro 50.000
– Number of patient
• Drug x: euro 50.000 / 1.750 = 28.5 patients
• Drug y: euro 50.000 / 2.000 = 25.0 patients
– Survival in days
• Drug x: 28.5 patients x 300 days = 8.550 days
• Drug y: 25.0 patients x 400 days = 10.000 days
– Survival in TWiST
• Drug x: 28.5 patients x 190 TWiST = 5.415 days
• Drug y: 25.0 patients x 220 TWiST = 5.500 days
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TWiST:
ignores differences in quality of life
• TWiST
– Healthy = 1
– Sick (dead) = 0
• There is more to life than sick/health
– Make intermediate values
– Q-TWiST
• Quality of life adjusted adjusted TWiST
• How to scale quality of life?
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Value a health state
• Wheelchair
– Some problems in walking about
– Some problems washing or dressing
– Some problems with performing usual activities
– Some pain or discomfort
– No psychosocial problems
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Time Trade-Off
• TTO
• Wheelchair
– With a life expectancy: 50 years
• How many years would you trade-off for a cure?
– Max. trade-off is 10 years
• QALY(wheel) = QALY(healthy)
– Y * V(wheel) = Y * V(healthy)
– 50 V(wheel) = 40 * 1
• V(wheel) = .80
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EuroQol EQ-5D:
of the shelf QALY value
•
•
•
•
•
MOBILITY
– I have no problems in walking about
– I have some problems in walking about
– I am confined to bed
SELF-CARE
– I have no problems with self-care
– I have some problems washing or dressing myself
– I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or
leisure activities)
– I have no problems with performing my usual activities
– I have some problems with performing my usual
activities
– I am unable to perform my usual activities
PAIN/DISCOMFORT
– I have no pain or discomfort
– I have moderate pain or discomfort
– I have extreme pain or discomfort
ANXIETY/DEPRESSION
– I am not anxious or depressed
– I am moderately anxious or depressed
– I am extremely anxious or depressed
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In health economics:
Q-TWiST = QALY
• Count life years
• Value (V) quality of life (Q)
– V(Q) = [0..1]
• 1 = Healthy
• 0 = Dead
– One dimension
• Adjusted life years (Y) for value quality of life
– QALY = Y * V(Q)
• Y: numbers of life years
• Q: health state
• V(Q): the value of health state Q
• Also called “utility analysis”
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Which health care program is the
most cost-effective?
• A new wheelchair for elderly (iBOT)
• Special post natal care
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Which health care program is the
most cost-effective?
• A new wheelchair for elderly
– Increases quality of life = 0.1
– 10 years benefit
– Extra costs: $ 3,000 per life year
– QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
– Costs are 10 x $3,000 = $30,000
– Cost/QALY = 30,000/QALY
• Special post natal care
– Quality of life = 0.8
– 35 year
– Costs are $250,000
– QALY = 35 x 0.8 = 28 QALY
– Cost/QALY = 8,929/QALY
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Effect psychotherapy
Clinic 12 months
1.0
Clinic 6 months
EQ-5D social values
0.9
Clinic 3 months
(STIP)
Out-patient clinic
0.8
0.7
0.6
0.5
Intake
1 year after
2 years
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Example STIP
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•
•
•
•
•
Short-Term Inpatient Psychotherapy
Cost price
– Per patient day: € 210.34
– 3 mouths = 91.3 day
– 91.3 x 210 = € 19,194.53
Includes overhead
– Buildings, administration, etc
Excluding
– Savings elsewhere in health care system
Effect
– Assume quality of life increase of 0.25
– Over 10 year
Cost / QALY
– 19,194.54 / (10 x 0.25) = € 7,677.41
Although gold
standard…
Cost per QALY of
psychotherapy
have never been
published
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QALY league table
Intervention
$ / QALY
GM-CSF in elderly with leukemia
235,958
EPO in dialysis patients
139,623
Lung transplantation
100,957
End stage renal disease management
53,513
Heart transplantation
46,775
Didronel in osteoporosis
32,047
PTA with Stent
17,889
STIP: Short-term inpatient psychotherapy
7,677
Breast cancer screening
5,147
Viagra
5,097
Treatment of congenital anorectal malformations
2,778
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Egalitarian Concerns:
Burden of disease
1.0
0.0
A
B
C
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Implications shifting threshold
• QALY are weighted
• Weighted QALYs are maximized
– Health is no longer the only thing maximized
• Health status population will drop
• Differences in health will drop
– Egalitarian consideration are incorporated
• Burden of disease becomes a criteria
– Equity
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CE-ratio by equity
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Burden of disease based on
STEP-data (N = 641)
1.0
0.8
0.6
0.4
0.2
0.0
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Conclusion
• Introduce state-of-the-art cost effectiveness studies
– Measure costs and outcome
• Suitable for cost effectiveness studies
• According to guidelines
• Establish burden of disease
– State-of-the-art quality of life research
• Use an active approach on budget constrains
– Anticipate on policy arguments
– Look for beyond own discipline
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